Gonzalez, Cesar

Abstract STUDY QUESTION What is the fertility preservation (FP) utilization rate among transgender and gender diverse (TGD) patients at the Transgender and Intersex Specialty Care Clinic (TISCC) within the Mayo Clinic? SUMMARY ANSWER The rate of utilization of FP services by TGD patients at Mayo Clinic’s TISCC was determined to be 6.62%. WHAT IS KNOWN ALREADY TGD patients encounter several barriers when pursuing FP, which may contribute to a lower utilization rate of these services. These barriers include financial constraints and lack of insurance coverage, as well as societal and healthcare provider attitudes; TGD individuals face discrimination or lack of understanding, making it uncomfortable or difficult to discuss FP options. Additionally, there continues to be a lack of inclusive policies and support within healthcare systems that can further impede access to FP services for TGD individuals. STUDY DESIGN, SIZE, DURATION The study was executed in two phases. In the first phase, a retrospective cohort study was completed with TGD patients who provided electronic health record (EHR) research authorization from Mayo Clinic’s TISCC in Rochester, MN between 1 January 2015 and 30 July 2021. Search terms related to FP were used to determine the FP utilization rate among this patient population. In the second phase of the study, two sets of patients, (i) patients who were included in the cohort study in Phase 1, and (ii) members of JASMYN, a community organization specializing in care and wellness coordination for Lesbian, Gay, Bisexual, and Transgender (LGBT) teens and young adults in North Florida. Individuals were invited to participate in a qualitative interview exploring their cumulative healthcare experiences accessing gender-affirming care. Interviews were conducted from January 2023 to June 2023. Interviews examined participants’ perceptions of FP options, motivations for pursuing FP, and barriers to accessing both gender and fertility care. When applicable, participants also discussed their experiences pursuing FP and reflected on their satisfaction with their fertility and family planning decisions. PARTICIPANTS/MATERIALS, SETTING, METHODS In phase 1, a total of N = 1189 patients sought care from Mayo Clinic’s TISCC in Rochester, MN. Out of these patients, N = 589 patients provided research authorization and were included in the retrospective cohort study. The study team assessed whether FP terms were mentioned in each patient’s EHR, and whether patients scheduled and attended appointments with either the Department of Reproductive Endocrinology or the Department of Urology. FP search terms included sperm cryopreservation, sperm extraction, sperm aspiration, testicular tissue cryopreservation, oocyte cryopreservation, embryo cryopreservation, and ovarian tissue cryopreservation. In phase 2, N = 36 participants were interviewed, with N = 25 participants recruited from Mayo Clinic’s TISCC in Rochester, MN, and N = 11 participants recruited from JASMYN in Jacksonville, FL. Participants recruited from the Mayo Clinic participated in a video-call-based interview and those enrolled from JASMYN were interviewed in person. MAIN RESULTS AND THE ROLE OF CHANCE The study team observed a 6.62% utilization rate of FP services among N = 589 patients (median age: 28 years; age range: 8–78 years) included in the retrospective cohort study. N = 39 patients completed FP, with N = 14 receiving these services at other institutions before seeking care with the TISCC at Mayo Clinic. N = 25 patients pursued FP services within the Mayo Clinic. Patients with testes were more likely to complete FP via sperm cryopreservation when compared to the utilization of egg cryopreservation among patients with ovaries. Participants who completed an interview in Phase 2 (median age 27 years; age range: 22–80 years) reflected on their decision on whether to preserve their fertility and what factors influenced these decisions, and how their satisfaction with this decision has changed over their lifespan. The major themes reported here include the desire for biological children, planning gender care around fertility desires, conversations about FP options, physical and psychosocial barriers to pursuing FP, reflections on personal FP decisions, and reflections on having to make decisions about FP at a young age. LIMITATIONS, REASONS FOR CAUTION All participants who completed an interview have done so voluntarily; as such, there is a possibility of selection and recall bias. WIDER IMPLICATIONS OF THE FINDINGS Findings suggest that there is a need for more structured conversations around FP when TGD patients seek medical and surgical gender-affirming care. Accessibility, including financial barriers and limited insurance coverage, continues to limit the utilization of FP services among TGD patients. Increased affordability through insurance coverage may additionally improve FP utilization. STUDY FUNDING/COMPETING INTEREST(S) This project was funded by the Mayo Clinic Department of Obstetrics and Gynecology and the Mayo Clinic Center for Clinical and Translational Science (CCaTS), grant number UL1TR002377. This project was also supported by Clinical and Translational Science Award (CTSA) Grant Number TL1TR002380 from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. Felicity Enders reports grants from the National Institutes of Health and the Agency for Healthcare Research and Quality paid to her institution; speakers’ fees for lectures or presentations from Mount Sinai, University of Washington, University of Minnesota, University of Rochester, Cincinnati University, the National Institutes of Health, Duke University, Wake Forest University, the Patient Centered Outcomes Research Institute, Johns Hopkins University; travel support from the Association for Clinical and Translational Science and Cold Spring Harbor Laboratory; and an unpaid leadership role on the Board of Directors of the Association for Clinical and Translational Science. All other authors declare no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.

Abstract Background Medical chaperones are authorized individuals present during physical examinations involving the genitals, breasts/chest, or anal areas. The use of medical chaperones may provide an opportunity to improve transgender and gender diverse (TGD) patients’ experiences with sensitive examinations. Aim To examine TGD adult patients’ preferences and comfort for having a medical chaperone and whether TGD-specific characteristics, social anxiety symptoms, and feelings of medical mistrust are associated with preference for having a medical chaperone present during a sensitive physical examination. Methods This study used a cross-sectional survey that randomly sampled adult patients from a gender clinic in the Midwest region of the U.S. A total of 420 surveys were mailed. Sixty-two surveys were returned undeliverable, 358 reached recipients; 151 were returned (42.1% response rate). The survey included items related to demographics, gender-related anatomical dysphoria, social anxiety symptoms, feelings of medical mistrust, and preference and comfort towards medical chaperones. Results Among 149 respondents, 74 (49.7%) reported comfort for the idea of having a medical chaperone present during a sensitive physical examination, 50 (33.6%) reported neutral comfort, and 25 (16.8%) reported discomfort. Among 147 respondents, 89 (60.5%) endorsed a preference for a female medical chaperone. We found no associations between gender-related anatomical dysphoria or social anxiety symptoms and comfort for having a medical chaperone, or the gender preference for a medical chaperone. Medical mistrust was associated with lower comfort with having a medical chaperone present during a sensitive physical examination. Clinical Implications Routinely offering medical chaperones, especially female chaperones, is like to be generally acceptable to most TGD patients. These findings may inform clinic policies on providing medical chaperones during sensitive examinations. Strengths and Limitations This study is the first to examine TGD preferences for medical chaperones. Findings are limited by a single site, homogeneous sample, cross-sectional design, and reliance on hypothetical rather than observed examinations. Conclusion TGD adults report comfort with the concept of having a medical chaperone during sensitive examinations and most would prefer the chaperone to be female. Preference for having a medical chaperone present during a sensitive physical exam is not likely influenced by gender dysphoria or social anxiety.

Abstract Context Transgender and gender diverse (TGD) individuals have greater access to genital surgery (GS) with improved insurance coverage and access to trained surgeons and interdisciplinary gender-affirming providers. Objective To determine perioperative medical and behavioral health outcomes in transfeminine (TF) individuals undergoing GS, with use of a specific gender-affirming hormone therapy (GAHT) algorithm based on individualized risk factor assessment. Methods In this retrospective observational cohort study, we collected preoperative and postoperative data from 183 TF individuals at a single tertiary referral center from 2017 to 2022, grouping patients by those who continued estradiol (Group 1) vs those who had temporarily discontinued estradiol for 2 to 6 weeks preoperatively (Group 2). Data included clinical and biochemical assessment, GAHT regimens, validated behavioral health measures, and postoperative complications. Main outcomes included venous thromboembolism (VTE) incidence, non-VTE postoperative complication incidence, and change in behavioral health assessments. Results The majority of individuals continued estradiol perioperatively (Group 1; 138 [75.4%]). Individuals who temporarily held estradiol preoperatively (Group 2; 45 [24.6%]) were statistically older (P < .01), had higher incidence of cardiometabolic comorbidities (P < .01), and higher Caprini scores (P < .01). Group 1 was statistically more likely to use oral estradiol (P < .01). One episode (0.05%) of VTE occurred (Group 1). There was no significant difference in postoperative complications or behavioral health measures between groups. Conclusion An individualized algorithm for preoperative hormone management for TF GS resulted in perioperative continuation of GAHT for the majority of individuals without significantly increasing the risk for postoperative surgical complications, while maintaining stable behavioral health measures perioperatively.

Introduction: More than 50% of primary care physicians’ practice involves sedentary desk work. Growing evidence suggests a link between sedentary workplace behaviors and increased morbidity and mortality. Research on the effects of sit-stand desks in the workplace suggests that sit-stand desks reduce sedentary behaviors. This study examined the use and satisfaction of adjustable desks with a height of sit-stand and their association with physical self-care behaviors among family medicine residents. Methods: We conducted a longitudinal cohort survey study at a 9-9-9 family medicine residency after the clinic installed height-adjustable sit-stand desks in January 2020. Standardized questions about the use and satisfaction of adjustable sit-stand desks and physical self-care behaviors were administered in June 2020, December 2020, and December 2021. The survey also included an open text box for feedback. Results: Median time spent standing at the sit-stand desks was 55.0%. The percentage of time standing was similar across June 2020, December 2020, and December 2021. The average satisfaction rate with the desks across all time points was 71.4%. We did not observe significant differences in the proportion of residents’ satisfaction with the adjustable desks over time. Residents who reported standing at the adjustable desk reported increased satisfaction with the desks (Kendall’s τ=.38, P<.001) and with physical self-care behaviors (Kendall’s τ=.25, P<.05). Themes associated with desk dissatisfaction revolved around limited desktop space. Conclusion: Over a nearly 1.5-year period, more than half of family medicine residents reported standing at their adjustable desks and being satisfied with them. Residents who reported standing at adjustable desks also reported increased physical self-care behaviors. Residency programs investing in sit-stand desks may consider options that allow for increased desktop surface space.

Introduction: Transgender and gender diverse individuals may choose to provide their infants with human milk. Lactating transgender men may experience gender dysphoria and desire to initiate or reinitiate gender-affirming testosterone therapy. However, there is limited safety data regarding use of testosterone during lactation. Main Issue: A 30-year-old G2P2 transgender man with gender dysphoria sought to initiate gender-affirming testosterone therapy while lactating. Management: Subcutaneous testosterone was self-administered beginning at 13 months post-partum. We prospectively collected data on circulating testosterone concentrations in parent serum, milk, and infant serum over 5 months until the infant self-weaned. The infant was monitored for growth and development at routine pediatric outpatient appointments. Parent serum testosterone concentrations rose with the initiation of testosterone therapy, reaching therapeutic concentrations by Day 14. Milk testosterone concentrations also increased with a maximum concentration of 35.9 ng/dl when the lactating parent was on a dose of 80 mg subcutaneous testosterone cypionate weekly. The calculated milk/plasma ratio remained under 1.0 and the calculated relative infant dose remained under 1%. The infant had no observable side effects, and his serum testosterone concentrations remained undetectable throughout the study period. Conclusion: This is the first study with data regarding human milk and infant serum testosterone concentrations during the initiation of gender-affirming testosterone therapy in a lactating individual. This evidence can help families and clinicians with decisions regarding lactation and testosterone use.

An estimated 1.4 million transgender adults live in the United States; this equates to approximately 0.6% of the U.S. population (Lane et al., 2018). Clinical focus on gender dysphoria has significantly increased over the past 30 years (MacCarthy, Reisner, Nunn, Perez-Brumer, & Operario, 2015), with burgeoning evidence from across disciplines documenting the positive outcomes associated with gender-affirming interventions. The purpose of this article is to illustrate how RNs optimize psychosocial, hormonal, and surgical gender-affirming care through performing comprehensive assessments, coordinating care, and providing education and health coaching.

Objectives To (1) test whether patient attitudes toward intake forms at three Midwestern outpatient clinics are significantly more negative among those who are asked to complete SOGI questions versus those who are not; and (2) gain an in‐depth understanding of patient concerns about SOGI questions. Study Setting Data were collected between 6/29/2015 and 2/29/2016 from new patients ( N = 491) who presented at three outpatient clinics in a large academic medical center. This study was originally a quality improvement project, and later, institutional review board approval was obtained for secondary data analysis. Study Design Two‐stage mixed‐methods study. (1) Experimental: New patients at three sites were randomly assigned to complete either routine intake forms (control) or routine intake forms with SOGI questions (experimental); and (2) qualitative: interviews with patients who responded negatively to SOGI questions. Principal Findings There were no significant differences in patient attitudes between experimental and control groups ( p > .05). Of those who received SOGI questions, only 3 percent reported being distressed, upset, or offended by the SOGI questions. Conclusions Collection of SOGI data as a part of the routine clinical patient intake process is not distressing to 97 percent of patients who are heterosexual, cisgender, and older than 50 years.

Background: Collaborative care management (CCM) is an evidence-based model that contributes to better outcomes for depression treatment in the primary care setting. Tobacco use increases overall economic costs, morbidity, and mortality and has been shown to impact behavioral health outcomes. Our study aims to observe clinical outcomes for depression treatment for patients with comorbid tobacco use and depression within the CCM model. Methods: A retrospective chart review study of 2826 adult patients with depression enrolled in CCM was performed to determine the association between regular tobacco use and depression outcomes. Baseline intake data consisting of clinical and demographic variables along with 6-month follow-up of Patient Health Questionnaire-9 (PHQ-9) scores for smokers (n = 727, 25.7%) and nonsmokers (n = 2099, 74.3%) were obtained. Depression remission was defined as a PHQ-9 score <5 and persistent depressive symptoms (PDS) as a PHQ-9 score ≥10 at 6 months. Results: Using an intention-to-treat analysis, the multivariate modeling demonstrated that smokers, at 6 months, had an increased adjusted odds ratio (AOR) for PDS: 1.624 (95% CI: 1.353-1.949). Furthermore, smokers had a lower AOR of depression remission: 0.603 (95% CI: 0.492-0.739). Patient adherence to treatment was also lower in smokers with an AOR of 0.666 (95% CI: 0.553-0.802). Conclusions: Smokers enrolled in CCM were associated with reduced treatment adherence and worse outcomes for depression treatment at 6 months compared to nonsmokers, even when baseline clinical and demographic variables were controlled. Thus, new tailored practices may be warranted within the CCM model to treat comorbid depression and tobacco use disorders.

Background: Lack of wellness among physicians has been associated with increased risk for physical and mental illness, interpersonal discord, and occupational liability. In academic primary care practices, physician wellness and self-care behaviors have been associated with improved patient outcomes. With the increase in team-based care structures in primary care clinics and residencies there may be opportunities to promote wellness among primary clinicians, particularly among resident physicians who are at increased risk for decreased well being. The primary objective of the study was to test an a priori hypothesis that family medicine residents’ perception of support from preceptor team leads would be associated with wellbeing. A secondary objective of the study was to test a post hoc hypothesis that examined whether the relationship between residents’ perception of support from their preceptor team leads would be associated with residents’ well being, while controlling for self-care behaviors. Methods: Our study utilized a prospective cross-sectional design with purposive sampling to survey family medicine residents. Data were collected in February 2016. The survey was sent out to 58 family medicine residents across three family medicine residencies at Mayo Clinic. The survey response rate was 55% (n=32); Ten (31.3%) residents reported being in their PGY-1, 11 (34.4%) in PGY-2; and 11 (34.4%) in PGY-3; participants included 19 (59.4%) women and 13 (40.6%) men. The Brief Resident Wellness Profile (BRWP) was utilized to assess family medicine residents’ perceived sense of professional accomplishment and mood in the past week. Results: In bivariate correlational analyses, increased perception of support from preceptor team leads (r=.40, P&lt;.01) and reporting a male gender (r=.43, P&lt;.01) was associated with increased resident wellness. In exploratory multivariate analysis, results suggested that while controlling for gender, frequency of self-care behaviors, and perceived preceptor team lead support, a one-point change on rating of perceived team leader support is associated with a 1.69 increase in resident wellness score on the BRWP. Conclusions: Our results provide preliminary evidence to support the relationship between preceptor team lead support and resident wellness in team-based care, above and beyond the impact that self-behaviors have on wellness. Our findings suggest evidence for the subsequent study of the impact of preceptor team lead relationship quality on resident wellness.